KINDER KUSTOM BTR _ �� N a
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD, ATLANTIC BEACH,FL 3223 �i iGc t S
LOCAL BUSINESS TAX APPLICATION
AtL
__
�,-(,�ec ��CeiL
Section 1 P�n�, -�
APPLICATION TYPE: New Business
Transfer of Ownership 1
Transfer to New Location: Previous Location
BUSINESS NAME: x-14, .--
LOCATION ADDRESS: W
MAILING ADDRESS: g�z e--j
BUSINESS PHONE: FAX:
11
2 �./P�l
EMAIL ADDRESS:
./� id (AP
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Emplooyer I.D.Number
Security
Social Se y Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
A
SQUARE FOOTAGE OF BUSINESS PREMISES: o»
(Include both buildings and outside areas used in conjunction wiEtebusines , ut not patron parking areas.)
Will the following be served? Food: Yes No 2COP 4COP
Alcohol: Yes No If yes, Select One: ICOP
If restaurant,will dogs be allowed? Yes
you have vending machines? Yes /-.%\ If yes, please provide quantity and type below:
Willy any
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER: ��✓
HOME ADDRESS:
HOME PHONE: CELL: a copy.)
`3- 6-- —rJ�,r Please attach
DATE OF BIRTH: "L �' �DRIVERS LICENSE#: C-0 1--79
EMAIL ADDRESS:
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy):
Section 3
I,the undersigned,swear that the above statements are true and correct and I agree to notify the City Clerk if there is
any change in the above information.
in no way
eves me
of the
I further understand that issuance of a Local Business Tax Receipt.by the City Clerk to reaibusiness n the
responsibility of compliance with all provisions of the Code of Ordinances pertaining
City of Atlantic Beach. / 0 TITLE: /V
t , t � l�=/'c--•
�LW
PRINT NAME:
DATE
SIGNATURE
n firm or corporation shall engage in or manage any trade, business, profession, o occupation
constitute approval
intla tic Be of
No person, P
without first obtaining a Local Business Tax Receipt. Application and/or payment does not c
a receipt.